We describe the technique of ultrasound-guided 18 gauge (1.2 mm) needle biopsy in 16 patients with parotid gland lesions. This provides material suitable for histological analysis and can be performed quickly and safely under local anaesthesia. Thirteen of the patients had non-diagnostic blind fine-needle aspiration cytology (FNAC) with a 21 gauge (0.8 mm) needle prior to biopsy. Initial ultrasound was found to be superior to clinical examination in 31 per cent of cases. The ultrasound-guided technique provided a diagnostic specimen in 100 per cent of patients and was helpful where FNAC had been inconclusive. There was a diagnostic accuracy of 100 per cent in the patients who underwent subsequent surgery. This method should be considered when FNAC is non-diagnostic and surgical treatment is being considered. It is particularly useful in patients with diffuse enlargement of the gland and does provide a core of material for accurate assessment of tissue architecture. In this series, nine patients avoided unnecessary surgery.

The large so-called type I afferents of the cochlear nerve carry the majority of the auditory input from the cochlea to the cochlear nuclei in the brainstem. These fibres are excitatory and previous studies have suggested they may use glutamate as their neurotransmitter. In the present investigation therefore, antibodies to glutamate and to the glutamate precursor, glutamine, were applied to resin sections of perfusion-fixed brains and of in vitro brain slices subjected to depolarizing levels of potassium before fixation to study glutamate handling and synaptic release. Ultrathin sections were labelled by the immunogold technique, and the immunoreactivity was quantified by recording the density of gold particles over the various tissue profiles. Non-primary, presumably inhibitory, terminals and glial processes were used as reference structures. The cochlear primary terminals proved to be strongly immunoreactive for glutamate. The density of glutamate labelling was higher in primary terminals than in non-primary ones, and lowest in glial processes. The ratio between the mean glutamate and glutamine labelling densities was also higher in primary terminals than in non-primary ones, and lowest in glial processes in each case. In the primary terminals, the glutamate immunoreactivity was higher over vesicle-containing regions than over vesicle-free regions, whilst glutamine was evenly distributed throughout. The in vitro brain slices showed a potassium-induced, partly calcium-dependent depletion of glutamate from the primary terminals but not from the non-primary ones. These observations strongly support the conclusion that glutamate is a neurotransmitter of type I cochlear afferents.

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Extramedullary plasmacytoma is a rare plasma cell neoplasm that can occur in the head and neck. In this article we describe a case of multiple synchronous extramedullary plasmacytomas involving the Lipper airway, pharynx, and larynx. The clinical, imaging, and pathologicfeatures of this neopla sm are discussed, together with potential treatment options. IntroductionExtramedullary plasmacytomas are rare neoplasms that occur in soft tissues at single and multiple sites.'? Most extramedullary plasmacytomas occur in the upper aerodigestive tract and oral cavity. In this report we describe the clinical, imaging, and pathologic features and report a case in which multiple lesions involved the upper airway and pharynx. Case reportA 71-year-old man presented with a 6-month history of a hoarse voice. He had no other symptoms , and the initial clinical examination was unremarkable . Microlaryngoscopy revealed a mucosal nodule on the soft palate with several other nodules present in the left and right supraglottic regions (figure 1).Biopsies were taken from a left supraglottic nodule, which demonstrated the replacement of the submucosal stroma with dense sheets of plasma cells. On immunohistochemical staining, these cells showed kappa immunoglobulin

A 50-year-old woman was admitted to the intensive care unit (ICU) for a life-threatening exacerbation of asthma requiring intubation and ventilation for 7 days. On day 8, she was stepped down from the ventilator via the insertion of a tracheostomy to aid weaning. It was initially decided that a percutaneous tracheostomy would be attempted on ICU, however, following further consideration, it was decided that due to anatomical factors (short neck) a surgical tracheostomy would be performed by the ear, nose and throat (ENT) team. A periprocedural USS was not performed. At surgery, instead of identifying two superficial anterior jugular veins lying on each side of the trachea, one large anterior jugular vein (median vein) was found overlying the entire anterior surface of the trachea. Had a PCT been attempted without an ultrasound scan being performed, this vessel would have been punctured, creating a significant bleed that could have placed the patient's airway and/or circulatory system at risk.

Continuous, endoscopically monitored electrokinetic lithotripsy with good irrigation gives a well illuminated field and absolute delivery of energy to the target. It avoids the side effects caused by impact of the shock wave on the parotid duct and adjacent anatomical structures, thereby making it a safer procedure.

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